Thibodaux Regional Fitness Center: Individual

Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

OK to Contact Home Phone

Preferred Phone

Home

OK to Contact Email?

Emergency Contact

Name

Phone

Birth Date

Gender

Male Female Other

Source

Monthly 5th Payment

$73.93

$91.59

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Individual - Standard	$0.00	$67.00	$0.00	0
Individual - Standard	$33.00			0
Enrollment Fee	$50.00	$0.00	$0.00	0
Sub-Total	$83.00	$67.00
Tax	$8.59	$6.93
Total	$91.59	$73.93

Payments will then be processed on a Monthly 5th basis there after.

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